Provider Demographics
NPI:1437289972
Name:MOXON, RICHARD LEE (DC CCEP)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LEE
Last Name:MOXON
Suffix:
Gender:M
Credentials:DC CCEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N6463 S PIONEER RD
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-3853
Mailing Address - Country:US
Mailing Address - Phone:920-907-1283
Mailing Address - Fax:920-907-1285
Practice Address - Street 1:93 S PIONEER RD STE 200
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54936-1776
Practice Address - Country:US
Practice Address - Phone:920-907-1283
Practice Address - Fax:920-907-1285
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3019111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38880600Medicaid
35114Medicare ID - Type Unspecified
WI38880600Medicaid